When caring for a client who is at risk for increased intracranial pressure (ICP), which intervention should the nurse implement to assist in stabilizing ICР?

A client's chest tube becomes dislodged from the drainage system. Which action should the nurse take?

An adult client is transported via ambulance to the emergency department (ED) following a motor vehicle collision. On arrival the client reports experiencing severe upper back pain. The vital signs are a temperature of 98.6° F (37° C) orally, heart rate 145 beats/minute, respirations 26 breaths/minute, and blood pressure 70/40 mm Hg. Which change in assessment findings indicate that the client's condition is deteriorating?

After several days of sedation and mechanical ventilation, a client is successfully extubated and is placed on oxygen 40% by face mask. While making rounds, the nurse finds that the client is confused and is attempting to get out of bed. Vital signs are temperature 99.2° F (37.3° C), heart rate 112 beats/minute, respirations 16 breaths/minute, blood pressure 100/70, and oxygen saturation 98%. Which action should the nurse take?

While caring for a client with a cervical spine injury, which assessment finding should the nurse report to the healthcare provider immediately?

Patient Data

The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment.
Which assessment(s) should the nurse conduct? Select all that apply.

A man brings his wife to the emergency department (ED) because she is confused and restless. He tells the nurse that they were in a motor vehicle collision early today and his wife bumped her head on the dashboard. The husband is very concerned about his wife and refuses to leave her bedside. Which intervention is most important for the nurse to implement?

A client with left ventricular failure complains of a hacking cough that worsens at night and further complains that shortness of breath sometimes occurs upon wakening. Which intervention should the nurse include in the bedtime preparation?

An unconscious client is demonstrating pulseless ventricular tachycardia (PVT).The nurse checks the client's pulse and begins cardiopulmonary resuscitation (CPR). The defibrillator and crash cart arrive at the bedside and the client is shocked. Which action should the nurse implement next?

After two hours post coronary artery bypass surgery the client experienced a central venous pressure increasing from 13 mm Hg to 17 mm Hg within a half hour. The systolic blood pressure dropped to 90 mm Hg on inspiration and rose to 110 mm Hg on expiration. Heart sounds are distant upon auscultation, and decreased electrocardiogram (ECG) waveform amplitudes are assessed. Which is the cause of these clinical manifestations?

Patient Data